Veterinary Policy for Prescribing and Dispensing Opioids The Colorado State Board of Veterinary Medicine Adopted on October 13, 2016 Revised on December 14, 2017

Veterinary Policy for Prescribing and Dispensing Opioids

PREAMBLE In 2013, the misuse and abuse of prescription opioids became a public health epidemic in the United States. During the same year, 50 people died each month in Colorado from unintentional drug poisoning, bringing specific attention to the epidemic’s effect in the State. The epidemic continues to lead to human drug addiction, death from overdose, and increased costs to society. In order to address this epidemic, steps must be taken to prevent opioid diversion from occurring. The Colorado State Board of Veterinary Medicine (Board) recognizes that reversing the trend of opioid misuse and abuse requires coordinated efforts to increase public awareness, take-back events for safe disposal, addiction treatment and recovery options, and enforcement, among others. The Board and the veterinarians it regulates are one part of a multi-pronged solution. Consequently, veterinarians must consider potential issues related to animal owners and veterinarians diverting an animal’s medication, due to addiction or expected financial gain. In 2014, to help address this crisis, the Board endorsed the Policy for Prescribing and Dispensing Opioids that was adopted by the Colorado Dental Board, Colorado Medical Board, Colorado Podiatry Board, State Board of Nursing, State Board of Optometry, and the State Board of Pharmacy. At that time, the Board believed that opioid use in a veterinary practice setting requires a unique policy that provides meaningful guidance to veterinarians who treat a wide variety of animals in Colorado. The Board continues to believe a unique policy is appropriate, and recognizes the inherent challenges veterinarians face when prescribing opioids to various animals. If the client is diverting a patient’s medication, there is potential to exacerbate opioid misuse and abuse. However, limiting access to opioids may directly compromise a patient’s health. The veterinary, client, patient relationship (VCPR) can present unique challenges when veterinarians consider prescribing opioids. To assist the prescribing veterinarian, the Board developed this policy to provide guidelines. However, this policy does not have the force of law, nor does it set a standard of care for veterinarians. It represents the Board’s current thinking on this topic. The Board anticipates periodic review of and updates to this policy. Colorado veterinarians may use an alternative approach if the approach satisfies the requirements of the applicable statutes, regulations, and standard of care.

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Table of Contents Prescribing in the Veterinary Context

4

Before Prescribing or Dispensing Opioids

4

When Prescribing or Dispensing Opioids

8

Prescribing and Dispensing for Advanced Dosage

9

Client Education

11

Discontinuing Opioid Therapy

12

Appendix

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PRESCRIBING IN THE VETERINARY CONTEXT Definitions The veterinary, client, patient relationship (VCPR) can present unique circumstances when a veterinarian makes a prescribing decision. With this in mind, this policy utilizes the terms “client” and “patient” as defined below: Client = the patient’s owner, the owner’s agent, or a person responsible for the patient. Patient = means an animal that is examined or treated by a licensed veterinarian and includes herds, flocks, litters, and other groups of animals.

Challenges unique to veterinary practice Unlike other prescribers, veterinarians prescribe opioids to patients that cannot selfadminister. The human client is fully responsible for purchasing and administering the prescription to the patient as directed. Therefore, the potential for misuse, abuse and diversion by the client exists. Veterinarians must understand the importance of prescribing opioid medications safely to patients, and dispensing opioids safely to clients, within the current climate of Colorado’s prescription drug use and abuse epidemic. Diversion is a process by which individuals obtain, use, or sell an opioid for purposes other than the original reason for which it was prescribed. Those who seek opioids for misuse, abuse, or diversion may turn to the veterinarian community to obtain these controlled substances. The veterinarian should understand the prevalence of diversion, how to recognize potential signs, and how to prevent opioid abuse and misuse while managing the patient’s pain effectively and safely. In many cases, it may be the client’s spouse, child, parent, or friend who may be diverting the opioids.

BEFORE PRESCRIBING OR DISPENSING OPIOIDS Develop and maintain competence Veterinarians, including those who dispense, must maintain competence to assess and treat pain to improve function and relieve suffering. This includes understanding how to assess patients for pain and being familiar with the current information on pain management in animals and the use of opioids in their patients. In some clinical situations, consultation with a veterinary pain specialist certified by an American Veterinary Medical Association recognized veterinary specialty organization is appropriate. In addition, pharmacists must maintain professional competence in the appropriateness of therapy for animal patients. Page 4 of 16

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Veterinary Policy for Prescribing and Dispensing Opioids See the Appendix for a list of resources and tools for developing and maintaining competence.

Utilize safeguards for the initiation of pain management The decision to prescribe or dispense opioid medication for outpatient use may be made only after a proper diagnosis and complete evaluation, which should include a pain assessment, review of relevant data from the Prescription Drug Monitoring Program (PDMP), and re-evaluation. These safeguards apply any time an opioid is prescribed. Not all pain requires opioid treatment. Prescribers should not prescribe opioids when non-opioid medication is both effective and appropriate for the level of pain. When assessing pain in a patient, assessments for function are often a key component. Alternative therapies for pain management in animals should be considered before opioid treatment begins. Such alternative treatments can include, but are not limited to: nonsteroidal anti-inflammatory drugs and other non-controlled medications that reduce pain or inflammation, weight optimization, acupuncture, physical therapy and associated rehabilitation modalities, nutrition management, thermal modification, environmental modifications,

1. Diagnose Veterinarians should establish a diagnosis and legitimate medical purpose appropriate for opioid therapy through a documented history, physical exam, and/or laboratory, imaging or other studies. The Board also recognizes that legitimate purposes for opioid medications may include tranquilizing, sedating, and immobilizing patients. A current veterinary-client-patient relationship (VCPR) must exist. Because animals are nonverbal and cannot self-report the presence of pain, the burden lies with veterinary professionals based upon clinical findings and history provided by the client including: ●

● ●

Patient history regarding normal behavior patterns related to pain status. Assessing behavior is an integral part of the history-taking and physical examination. Behavioral signs of pain, including both loss of normal behavior and development of new and abnormal behavior may be subtle and easily overlooked. Patient medication history. Determine what drugs have or are being given in order to determine what future combinations may be unsafe or incompatible. Health conditions that could aggravate adverse reactions. These include age, size, species, breed, concomitant medications, overall clinical problems i.e. organ dysfunction. Page 5 of 16

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2. Assess Risk Veterinarians should conduct a risk assessment prior to prescribing opioids for outpatient use. Risk to the patient: Consider the signalment, concurrent medications, and co-morbid conditions when deciding if opioid use is appropriate for pain management in that patient.

3. Assess Pain Veterinarians have a responsibility to identify pain and relieve suffering in their patients. All animals experience pain but how pain is expressed can vary from species to species and with individuals within a species. Pain assessment usually involves evaluating for certain changes in behavior and/or physiologic data. Various species-specific pain scoring tools (Pain Scales) are available and veterinarians are encouraged to use these, when available, to help identify pain and evaluate response to therapy in a consistent manner. Some animals tend to hide their pain so it remains a challenge to accurately identify the degree of pain in every patient. In cases where the patient is subjected to an event that would be painful for a human, such as surgery or a traumatic injury, the veterinarian should conclude that the patient will also be experiencing pain and should be proactive and treat appropriately. Veterinarians should assess for pain and potentially painful conditions as part of the physical examination on every patient. A pain management plan should be recommended for patients identified with a painful condition. This may be a brief course of treatment for temporary conditions, or an ongoing therapy for conditions that cannot be corrected such as degenerative joint disease or incurable cancer. Preemptively and proactively treating pain and using multimodal therapies are generally associated with better outcomes. Opioids are one tool in the array of choices for pain management and should be used judiciously. An appropriate pain assessment should include, but is not limited to, an evaluation of the patient’s pain for: ● ● ● ● ● ● ●

Nature and intensity Type Pattern/frequency Duration Past and current treatments Underlying or co-morbid disorders or conditions Impact on physical functioning Page 6 of 16

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Veterinary Policy for Prescribing and Dispensing Opioids Factors that may amplify pain during the assessment include, but are not limited to: ● ● ●

Anxiety associated with veterinary visits A patient’s fear Physical restraint used during examination

Pain scoring tools such as identification and recording of behavior changes and responses to therapy are useful for standardizing pain assessment. There are different scales for assessing pain in different species. It should be noted that pain scoring tools for acute and chronic pain have varying degrees of validation. Acute and chronic pain scales are not interchangeable and species specific scales also are not interchangeable. However, the use of pain scoring tools can decrease subjectivity and bias by observers, resulting in more effective pain management. Individual veterinarians are encouraged to make use of pain scoring tools that are appropriate to their practice, and then use the same tools consistently for ongoing validation. See the Appendix for additional resources related to pain assessment.

4. Review PDMP Veterinarians, including those who dispense opioid medications, should utilize the Prescription Drug Monitoring Program (PDMP) prior to prescribing or dispensing. In 2017, state law related to a veterinarian’s use of the PDMP changed. If a veterinarian is authorized to prescribe controlled substances for animals and suspects a client has committed drug abuse or mistreated an animal, the veterinarian now may access the PDMP to inquire about a current patient or client. Previously, the veterinarian could query only the patient’s record. When using the PDMP as an assessment tool, please note that any opioid drugs dispensed from the veterinarian’s office, a legal practice in Colorado, are NOT entered into the PDMP, and therefore not tracked in PDMP. Only prescriptions dispensed by a pharmacy are uploaded to the PDMP. Veterinarians are encouraged to prescribe opioids that will be dispensed at a pharmacy, to ensure the information is entered into and tracked through the PDMP.

5. Re-evaluate In order to determine the appropriateness of ongoing therapy, veterinarians are encouraged to reassess the patient prior to re-prescribing opioids, and again before increasing dosage or duration. The reevaluating interval will depend on the procedure or condition, expected duration of the chosen intervention, and previous pain score.

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Collaborate with the healthcare team The healthcare team consists of the client, the veterinarian and his or her staff, and the pharmacist. The collaboration of this group prevents under-prescribing, overprescribing, misuse and abuse of opioids. Only prescriptions dispensed by a pharmacist will be included in the PDMP database. See the Appendix for additional resources.

WHEN PRESCRIBING OR DISPENSING OPIOIDS Verify a veterinary-client-patient relationship A current veterinary-client-patient relationship must exist. The veterinarian should identify a painful condition and document the need for opioids. Additionally, the veterinarian should verify the patient’s identification prior to prescribing or dispensing opioids to a new or unknown patient. When dispensing, a veterinarian should exercise judgment when the prescription order is: ● For a new or unknown patient ● For a weekend or late day prescription ● Issued far from the location of the pharmacy or patient’s residential address ● Denied by another veterinarian or pharmacist. Veterinarians and pharmacists can legally access the patient’s PDMP account and the client’s account when considering prescribing or dispensing a controlled substance prescription for the patient or if the veterinarian suspects a client has committed drug abuse or mistreated an animal.

Additional Safeguards Ensure the dose, quantity, and refills for prescription opioids are appropriate to improve the function, pain management, and wellbeing of the patient, at the lowest effective dose and quantity.

Dosage Recognize the vast differences among species when using certain drugs. For example, tramadol, an opioid pain medication used to treat mild to moderate pain, is rapidly metabolized in canines. Therefore, dosages for canines are higher than what is used in other animals, such as felines and equines. Such dosages should therefore be validated by pain score tests to determine the need or efficacy of long-term use. Page 8 of 16

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PRESCRIBING AND DISPENSING FOR ADVANCED DOSAGE Palliative and Hospice Care_______________________________________ Palliative care is defined as the active, total care of patients with disease that is not responsive to curative treatment. Pain control is often an important feature of this type of care. The goal is to achieve the best quality of life (QOL) for patients and their owners, and assumes ongoing assessment of QOL in the terminally ill patient. This standard often leads to an increased use of opioid medications, as well as the possibility of diversion of opioid medications that remain after the death of the patient. Veterinarians are encouraged to consider the possible expected life span of the patient and carefully estimate the amount of opioids needed when prescribing in these situations. Veterinarians also are encouraged to educate the client on proper disposal techniques for unused opioid medications. For instance, “take-back” events are preferable to flushing prescriptions down the toilet or throwing them in the trash. Hospice is designed to provide compassionate comfort and care to patients at the end of their lives and to support their owners in the bereavement process. Increasingly, as consumers choose euthanasia less frequently or at a much later time, palliative and hospice care are becoming a more common standard of care. This standard will often lead to an increased use of opioid medications. Further, consumer demand by clients for pain management for the patient may also lead to an increased use. User-friendly QOL assessment scales are available to help veterinarians, veterinary staff, and clients make proper assessments and decisions at the end of a patient’s life. It is generally agreed that the healthcare team is best suited to evaluate QOL, but a team approach emphasizing regular communication (discussed in the next section of these guidelines) is important to provide empathetic support when end-of-life decisions are made. See the Appendix for additional resources.

Monitoring The prescribing and dispensing of opioids for chronic pain must be monitored on an ongoing basis, such as: ● ● ● ●

assessing the effectiveness of the treatment assessing the ongoing need for the opioid medication assessing quality of life scale periodically rechecking the PDMP for a patient, client or both

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Veterinary Policy for Prescribing and Dispensing Opioids This monitoring should be documented in the patient’s medical records or a treatment agreement signed by the client. Prescribers should not increase an initial opioid dosage without rechecking the PDMP.

Prescriber Awareness Veterinarians who prescribe and dispense controlled substances should use clinical judgment when aberrant drug-related behaviors are observed in a client and should be aware of drug seeking behavior. Aberrant behavior should be reported to the proper authorities and/or healthcare team as appropriate. Veterinarians also should be aware that opioid misuse, abuse and diversion often starts with a valid prescription, but medication can be diverted by someone other than the client from a medicine cabinet or unsafe location. Signs to look for include: ● ● ● ● ● ● ● ● ● ●

“Pattern prescribing” - knowledge of prescriptions for the same drugs and the same quantities coming from another prescriber. Geographic anomalies between client and veterinary facility or pharmacy. Shared addresses by clients presenting on the same day. Request by client for early refills of the prescribed opioid. Request by a new client for a specific opioid for their pet. A new client that has seen multiple veterinarians in the area. Request by client for increased prescribing of controlled substances in general. Request by client for large quantities and strengths of medication. A client willing to pay cash for appointments or prescriptions. Knowledge of fraudulent patient prescriptions in the past.

As prescribers of controlled substances, please be aware that pharmacists who dispense these prescriptions are also checking the PDMP. Should you receive a phone call from a concerned pharmacist, remember that the pharmacist is equally responsible for the content and safety of a controlled substance prescription, and is looking out for the safety of the patient. See the Appendix for resources on Prescriber Awareness.

Addressing Suspected Diversion As a veterinarian who has noticed any of the red flags or warning signs of prescription drug abuse, misuse, or diversion, you may need to consider speaking to the patient’s owner about this issue. The Board recognizes these conversations can be difficult. See the Appendix for references to help initiate and guide these conversations. Page 10 of 16

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Options to consider if you Suspect Diversion Contact law enforcement authorities: ● ●

If a veterinarian suspects illegal activity, the matter should be referred to the Drug Enforcement Agency (DEA) and local law enforcement. If a veterinarian suspects illegal activity on behalf of another prescriber or dispenser, at a minimum, the matter should be reported to the appropriate licensing board at the Department of Regulatory Agencies.

CLIENT EDUCATION Veterinarians are encouraged to educate their clients about potential behavioral changes associated with the use of prescribed opioids. . Regardless of the dosage, formulation and duration of opioid therapy, veterinarians should educate clients on proper use, risks of addiction, alternatives, storage, proper disposal of opioids, and the potential for diversion. Risks may include but are not limited to: ● Overdose ● Misuse ● Diversion ● Addiction ● Physical dependence and tolerance ● Interactions with other medications or substances ● Death Providers should educate clients about the risks and benefits of medications that exceed the dosage, formulation and duration guidelines indicated above that may place the patient at increased risk for long-term dependence and unintended adverse drug effects. When alerted to these risk factors, clients can make more informed decisions about their patient’s health care treatment. For example, some clients have reduced or foregone opioids when alerted to the risk factors. If a decision is made to continue with opioid therapy, a satisfactory response to treatment would be indicated by a reduced level of pain, increased level of function and/or improved quality of life. The use of a healthcare team and family members of the client may be considered as a part of the treatment plan and ongoing monitoring. See the Appendix for resources on preventing diversion through appropriate disposal.

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Client Education Plan In certain cases, veterinarians may want to utilize a formal client education tool, often referred to as a “treatment plan”, and should explain the client’s responsibilities with regard to the plan. A plan may include, but is not limited to, the following information: ● ● ● ● ●

● ● ●

Goals of treatment Client education (proper use, risks of addiction, alternatives) Controls (single prescriber, single pharmacy for refills) Proper use of opioids, potential side effects, and alternatives. Information regarding signs of pain in animals so the client may participate in the evaluation of the adequacy of treatment or the need for continued treatment. Discussing the need for periodic assessments by the veterinarian of the patient’s condition. Proper storage, disposal, and diversion precautions (including detailed precautions related to adolescents and/or children and visitors to the home). Process and reasons for changing/discontinuing the treatment plan; communicating reduction or increase of symptoms; and referring to a specialist.

It is important to note that educating the client is not intended to create barriers relative to the patient receiving treatment. The education is intended to inform and for safety purposes. Additionally, a plan can provide an additional layer of monitoring if properly structured. See the Appendix for resources on sample agreements.

DISCONTINUING OPIOID THERAPY The veterinarian should consider discontinuing opioid therapy when: ● ● ● ● ● ●

The underlying painful condition is resolved; Intolerable side effects emerge; The analgesic effect is inadequate; The patient’s quality of life fails to improve; Functioning deteriorates; or There is aberrant medication use by the client.

The veterinarian discontinuing opioid therapy should employ a safe, structured tapering regimen, and possibly seek assistance from a pain specialist for a particular species. See the Appendix for tips on tapering. Page 12 of 16

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APPENDIX PDMP Colorado Prescription Drug Monitoring Program (PDMP): www.colorado.gov/dora-pdmp

Preventing diversion through appropriate disposal In order to prevent diversion, providers should provide information regarding appropriate disposal, including the following: ● Secure unused prescription opioids until such time they can be safely disposed. Specifically, ensure that prescription opioids are not readily accessible to other family members (including adolescents and/or children) or visitors to the home. ● Take-back events are preferable to flushing prescriptions down the toilet or throwing them in the trash. Only some medications may be flushed down the toilet. See the FDA’s guidelines for a list of medications that may be flushed: www.fda.gov. www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm ● Utilize take-back events and permanent drop box locations ● Utilize DEA disposal guidelines if take-back or drop boxes are unavailable. Those guidelines include: ● Take the drugs out of their original containers and mix them with an undesirable substance, such as used coffee grounds or kitty litter; then put them in a sealable bag, empty can, or other container to prevent the medication from leaking out of a garbage bag; ● Before throwing out a medicine container, tell the patient to scratch out all identifying information on the prescription label to protect their identity and personal health information; and ● Educate clients that prescriptions are patient specific. Veterinarians should be aware there is a risk that clients may improperly share prescription opioids with individuals and animals other than the patient. ● Use activated charcoal absorption technologies to inactivate unused medications or used fentanyl patches.

Record keeping Veterinarians who treat patients with opioids should maintain accurate and complete medical records according to the requirements set forth by their licensing board and the Drug Enforcement Agency (DEA).

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Aberrant drug-related behavior Prescribers and dispensers should use clinical judgment when aberrant drug-related behaviors are observed. Such behavior should be reported to the proper authorities and/or healthcare team as appropriate. Aberrant drug-related behaviors broadly range from mildly problematic (such as hoarding medications to have an extra dose during times of more severe pain) to felonious acts (such as selling medication). These are any medication-related behaviors that depart from strict adherence to a prescribed therapeutic plan of care. Prescribers and dispensers should observe, monitor and take precautionary measures when a client presents aberrant drug-related behaviors such as: ● ● ● ● ● ● ● ● ● ● ● ● ●

Requesting early and/or repeated refills Presents at or from an emergency department seeking high quantities of a prescription Denied by other prescribers or dispensers Presents what is suspected to be a forged, altered or counterfeit prescription. Forging prescriptions Stealing or borrowing drugs Frequently losing prescriptions Aggressive demand for opioids Injecting oral/topical opioids Unsanctioned use of opioids Unsanctioned dose escalation Getting opioids from multiple prescribers Recurring emergency department visits for chronic pain management*

Prescribers and dispensers also should be alert for subjective behaviors such as being nervous, overly talkative, agitated, emotionally volatile, and evasive, as these may be signs of a psychological condition that may be considered in a treatment plan or could suggest drug misuse.** *“Interagency Guidelines on Opioid Dosing for Chronic Non-Cancer Pain” State of Washington Agency Medical Directors Group. 2010 Online: www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf **Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain. Sunrise River Press, North Branch, MN 2007.

Practitioner Considerations Healthcare team: Consider that the patient may be receiving opioids from another veterinarian. Contact the patient’s healthcare team when appropriate which may include the following: ● Veterinarian ● Technicians and staff Page 14 of 16

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Patient-care personnel

Veterinarians should be aware that there is no legal obligation to prescribe or dispense a prescription.

Risk Assessment The PLATTER Approach to Pain Management The PLATTER method provides individualized pain management for any patient and is devised not on a static basis but according to a continuous cycle of plan-treat-evaluate based on the patient’s response. The PLATTER approach involves the following: ● Plan: Every case should start with a patient-specific pain assessment and treatment plan. ● Anticipate: The patient’s pain management needs should be anticipated whenever possible so that preventive analgesia can either be provided or, in the case of preexisting pain, so that it can be treated as soon as possible. ● Treat: Appropriate treatment should be provided that is commensurate with the type, severity, and duration of pain that is expected. ● Evaluate: The efficacy and appropriateness of treatment should be evaluated, in many cases, using either a client questionnaire or an in-clinic scoring system. ● Return: It can be argued that this is the most important step. This action takes us back to the patient where the treatment is either modified or discontinued based on an evaluation of the patient’s response.

Assess Pain Acute Postoperative Pain Scales: Resource Colorado State University Canine Acute Pain Scale

Internet Address http://www.csuanimalcancerce nter.org/assets/files/csu_acute _ pain_scale_canine.pdf

Content Psychological and behavioral indicators of pain Response to palpation

Colorado State University Feline Acute Pain Scale

http://csuanimalcancercenter.o rg/assets/files/csu_acute_ pain_scale_feline.pdf

Same as above

University of Glasgow Short Form Composite Pain Score

http://www.newmetrica.com/c mps/

Clinical decision-making tool for dogs in acute pain Indicator of analgesic requirement Includes 30 descriptors and 6 behavioral indicators of pain

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http://www.animalpain.com.br /en-us/avaliacao-da-doremgatos.php

Assesses postoperative pain in cats Includes 10 indicators of pain ranked numerically

Multifactorial Clinical Measurement Instruments (CMIs) for Chronic Pain Assessment in Veterinary Medicine: ● ● ● ● ● ●

Helsinki Chronic Pain Index (HCPI) Canine Brief Pain Inventory (CBPI) Cincinnati Orthopedic Disability Index (CODI) Health-Related Quality of Life (HRQL) Liverpool Osteoarthritis in Dogs (LOAD) Feline Musculoskeletal Pain Index (FMPI)

Additional Resources and Tools Establishing and maintaining competence: Tenney, Lili and Lee Newman. “The Opioid Crisis: Guidelines and Tools for Improving Pain Management” Center for Worker Health and Environment, Colorado School of Public Health. Pain tool kit: Various resources for assessing and managing pain including risk assessments, patient agreements, dose and conversion calculators among others. www.ImprovingHealthColorado.org Drug abuse resources: Substance Abuse and Mental Health Services Administration: www.samhsa.gov NIH National Institute on Drug Abuse: www.drugabuse.gov or www.nida.nih.gov

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